Documentation must include the chief complaint and a brief history of the presenting illness (HPI) or problem.

System of medical recordkeeping that consists of flow sheets, charts, or graphs that allow a physician to quickly locate information and compare evaluations for data such as blood pressure readings, blood sugar levels for diabetic patients, weight for obese patients, medications, and immunizations.

1. ICD-9-CM diagnostic codes that are used when a person who is not currently sick encounters health services for some specific purpose such as to act as a donor of an organ or tissue, receive a vaccination, discuss a problem that is not in itself a disease or injury, seek consultation about family planning, request sterilization, or to obtain supervision of a normal pregnancy. In these situations the V code appears as a primary code and is placed first for the purpose of billing. 2. Codes used to identify a condition that might affect the patient at a future time but is not a current illness or injury. Use a V code to describe an existing situation that might influence potential medical care.

Specific action, process, sequence of steps, or test performed on a patient either to establish a diagnosis or render a therapeutic service (e.g., minor or major surgery, laboratory tests, inserting an intravenous line).

Five-digit numeric codes that describe each professional service the physician renders to a patient and used to communicate medical service data to insurance companies or government programs. These codes are used on insurance claims submitted to insurance programs for payment. Also referred to as CPT codes or procedural codes.

Standardized method used to transform written descriptions of procedures and professional services into numeric designations (code numbers).

Review of diagnostic and therapeutic procedures to determine appropriateness.

1. Face value of an insurance policy or annuity and any additions payable at maturity or death. 2. Under Medicare Secondary Payer guidelines, money obtained as a result of a transaction that is in the possession of the party to whom it was intended.